=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912024696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN B HARRISON DDS,MSC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 09/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 4TH AVE S
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-822-3156
-----------------------------------------------------
Fax | 727-822-3405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 4TH AVE S
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-822-3156
-----------------------------------------------------
Fax | 727-822-3405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3770
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------